52 SHORT UPPER LI THEN TOO AS WILL BE DEMONSTRATED IN SPECIFIC CASES VARYING THE SIMPLEST

Transcription

1 52 SHORT UPPER LI TWTT THE UPPER LIP IS SHORT IN VERTICAL HEIGHT IT EXPOSES TOO MUCH OF THE INCISORS AND REQUIRES LENGTHENING SEVERAL METHODS HAVE BEEN DESCRIBED TO INCREASE VERTICAL LIP LENGTH THEY CALL UPON TISSUE FROM THE EAR LATERAL LIP ELEMENTS AND CHEEKS THEN TOO AS WILL BE DEMONSTRATED IN SPECIFIC CASES VARYING DEGREES OF SHORT LIP CORRECTION CAN BE ACHIEVED WITHOUT EXCLUSIVE FOCUS ON LIP LENGTHENING SCAR EXCISIONS THE FORKED FLAP AD VANCEMENT OF THE TOTAL SHORT PROLABIUM INTO THE COLUMELLA FOLLOWED BY AN ABBE FLAP WITH MINOR ADJUSTMENTS TO THE LATERAL LIP SEGMENTS CAN ACHIEVE NOT ONLY SCAR IMPROVEMENT COLUMELLA LENGTH AND PHILTRUM CONSTRUCTION BUT LZJT LENGTH AS AN EXTRA DIVIDEND EAR GRAFTS THE SIMPLEST METHOD OF MINOR CENTRAL LIP LENGTHENING WHICH ALSO INGENIOUSLY CREATES THE SEMBLANCE OF CUPIDS BOW WAS DESCRIBED BY THE INTERESTING BRITISH TEAM OF MUIR OF ABERDEEN AND BODENHAM OF BRISTOL FOR GIBSONS 1966 MODERN TRENDS IN PLASTIC SURGERY THEY STATED OCCASIONALLY SIMPLE WAY OF LENGTHENING THE SHOTT SCARRED LIP IS REQUITED THROUGH AND THROUGH TRANSVERSE INCISION IS MADE ALONG THE MUCOCURANEOUS MARGIN AND THE RED MARGIN ALLOWED TO DROP THE LOZENGESHAPED DEFECT IS THEN FILLED WITH SUITABLE SHAPED DOUBLESIDED FULL THICKNESS LOBE GRAFT FROM RHE EAR THE WIDTH OF THE CORRECTION BEING PLANNED TO SIMULATE THE NATURAL CUPIDS BOW QNQ ITS ONLY DETRACTION MIGHT BE THE ENCIRCLING SCAR AND THE STUCKON EFFECT OF LITTLE EAR IN SCARRED LIP 629

2 LATERAL LIP FLAPS THE INTRODUCTION OF LATERAL LIP FLAPS ACROSS THE MIDLINE CAN OF COURSE LENGTHEN THE VERTICAL DIMENSION OF THE LIP WHEN THIS PRINCIPLE IS USED DURING THE PRIMARY BILATERAL CLEFT LIP SURGERY IT TOO OFTEN RESULTS IN LONG LIP WHEN THE SURGERY IS CARRIED OUT SECONDARILY AFTER FIVE YEARS OF AGE IT CAN ACHIEVE LENGTH UNDER MORE CONTROLLED ACCURACY THEN THE MAIN DETERRENT BECOMES THE UNNATURAL POSITION OF THE SCARS AND THE LACK OF MUSCLE CONTINUITY LOW ADVANCEMENT GINESTET STAIRSTEP METHOD OF ADVANCING THE LATERAL LIP ELEMENTS MEDIALLY UNDER THE LOWER BORDER OF THE PROLABIUM AS SECONDARY MANEUVER IS MENTIONED ONLY TO CONDEMNIT THE COST IN UNNATURAL SCARRING AND SIDETOSIDE VERTICAL LENGTHENING ACHIEVED TIGHTENING IS TOO GREAT FOR THE JJJ IF THIS IS BAD IN PRIMARY CLEFTS IT IS JUST AS DEFORMING IN SECONDARY DEFORMITIES MIDDLE ZPLASTIES THE ZPLASRY IS RENOWNED FOR ITS ABILITY TO LENGTHEN SHORT SEGMENT ALONG ONE AXIS BUT REMEMBER THIS IS AT THE EXPENSE OF TIGHTENING IN THE OPPOSITE AXIS ALTHOUGH BILATERAL ZPLASTIES HAVE BEEN AND WILL CONTINUE TO BE USED IN SHORT BILATERAL CLEFT LIPS IN MY OPINION THE SCARS VIOLATE NATURAL LINES AND LANDMARKS AND SHOULD BE USED IF AT ALL WITH CAUTION REMEMBER THE INTERDIGIRARIONS WILL NOT INCREASE THE TOTAL CENTER LENGTH OF THE SHORT PROLABIUM BUT ONLY THE ZIGZAGGED SIDES 630

3 1UGH TRANSPOSITION THE TRANSPOSITION OF VERTICAL FLAPS TO THE HORIZONTAL POSITION AS DESCRIBED BY TRAUNER MARCKS AND WYNN CAN BE CALLED UPON TO LENGTHEN SHORT LIP EVEN MORE THAN TO LENGTHEN COLUMELLA THERE IS AN UNNATURAL BOXLIKE SQUARE EFFECT OF THE SCARS FOLLOWING THE ELEVATION 90DEGREE TURN AND INSERTION OF BILATERAL FLAPS HIGH ADVANCEMENT OF ALL THE METHODS USING THE LATERAL LIP ELEMENTS TO LENGTHEN THE SHORT LIP IT SEEMS THAT THE HIGH ADVANCEMENT IS CLOSEST TO ACHIEVING THE NORMAL IT TIGHTENS UNDER THE BASE OF THE NOSE WHERE WIDTH IS USUALLY THE MOST ABUNDANT AND THE LEAST DESIRABLE AND LEAVES THE LIP FREE BORDER RELATIVELY RELAXED BILATERAL MEDIAL ADVANCEMENT OF THE LATERAL THE ALAR BASES AND COLUMELLA LIP ELEMENTS AT THE TOP JUST BENEATH PRESENTS SCARS OF UNION ALONG THE NATURAL NASAL CREASES AND PHILTRUM CURVES YET TO PRESERVE THE PHILTRUM EFFECT WHEN VERTICAL SHORTNESS IS NOR PRESENT THESE FLAPS ARE BETTER BROUGHT JUST SHORT OF TIP TO TIP FULL II ONLY WHEN THE LIP IS EXTREMELY SHORT SHOULD THE LATERAL FLAP TIPS TOUCH OR CRISSCROSS EVEN BY MILLIMETERS FORKED FLAP LENGTHENS LIP LEST THE FORKED FLAP BE CONSIDERED ONLY COLUMELLA LENGTHENER IT IS WELL TO POINT OUT THAT IT ALSO LENGTHENS THE LIP VERTICALLY AS IT TIGHTENS IT FROM SIDE TO SIDE THIS EFFECT IS OBVIOUS IF THE ACTION DURING CLOSURE OF THE DONOR AREA IS STUDIED AFTER THE FORK WITH THE SCARS IS ADVANCED OUT OF THE LIP THERE IS SOME RELEASE THEN WHEN THE LATERAL LIP FLAPS ADVANCE TOWARD EACH OTHER AT THE TIP OF THE 11 PHILTRUMS LITTLE POINTED HEAD THE LIP GROWSLONGER THIS IS AN 631 IL

4 IMPORTANT CONSIDERATION IF FORKED FLAP IS PLANNED AND THE LIP IS ALREADY TOO LONG ACTION TO SHORTEN THE LIP SUCH AS HIGH LATERAL TRANSVERSE WEDGE EXCISIONS SHOULD BE INCORPORATED IN THAT SPECIFIC FORKED FLAP DESIGN ABBE FLAP OFTEN FOLLOWED BY UPPER LIP LENGTHENING WHETHER THE PROLABIUM IS ADVANCED OUT OF THE LIP INTO THE COLUMELLA TO MAKE ROOM FOR AN ABBE FLAP OR THE CENTRAL SCAR IS EXCISED AND THE LIP DIVIDED TO RECEIVE THE ABBE FLAP THE FINAL ABBE FLAP INSERTION NOT ONLY RELEASES THE SIDETOSIDE TIGHTNESS BUT CAN ALLOW LIP LENGTHENING THE REASON IS THAT PREPARATION OF THE UPPER LIP FOR THE ABBE FLAP HAS REQUIRED THE SHIFTING OF SHORT TIGHT PROLABIUM OR THE EXCISION OF SCARS AND EITHER OR BOTH COULD HAVE BEEN ACTING TO SOME DEGREE AS SHORTENING RESTRAINT THUS IT IS IMPORTANT TO NOTE WHETHER OR NOT THE LIP IS OF SATISFACTORY VERTICAL LENGTH PRIOR TO THE LIPSWITCH SURGERY IF THE LATERAL ELEMENTS WHEN FREED BECOME TOO LONG THEY CAN BE TAILORED THE ABBE FLAP SHOULD BE CUT TO MATCH THE CORRECT LENGTH AND NOT THE RELEASED LENGTH FOR INDEED THE ABBE IS THE ENFORCER WHICH IF FASHIONED CORRECTLY CAN KEEP THE LIP RIGHT JOINING MUSCLES LENGTHENS LIP MANY OF US HAVE NOTED THAT WHEN THE LATERAL LIP MUSCLE FIBERS ARE JOINED TO EACH OTHER ACROSS THE CLEFT BEHIND THE PROLABIUM THERE IS SOME INCREASE IN VERTICAL LENGTH OFTEN IMMEDIATE BUT AT LEAST EVENTUAL CHEEK FLAPS WHEN THE UPPER LIP IS BOTH SHORT AND TIGHT AND THE LOWER LIP IS NOT REDUNDANT THE SURGEON MUST TURN TO THE CHEEK FOR TISSUE VARYING AMOUNTS ARE AVAILABLE FROM THE CHEEKS DEPENDING ON THE NEED 632

5 BILATERAL NASOLABIAL CHEEK FLAPS WERE DESCRIBED BY DIEFFENBACH IN 1845 FOR RECONSTRUCTION OF THE UPPER LIP AS HE PUBLISHED NO DIAGRAMS THE SCHOLARLY WEBSTER CAREFULLY INTERPRETED THIS FROM THE GERMAN TEXT DESIGN ESSER ALSO TRANSPOSED BILATERAL NASOLABIAL FLAPS INTO THE UPPER LIP BRINGING BOTH BODY AND LENGTH TO THE LIP WITHOUT SACRIFICE OF THE LOWER LIP THE DONOR SCARS OF CLOSURE HUG AND ARE HIDDEN IN THE ALAR CREASES 11TH THT CHARMING JUHN BARTON ANOTHER NEW ZEALANDER WHO BECAME PLASTIC SURGERY LEADER IN BRITAIN TRAINED WITH MOWLEM SERVED WITH IIIIES AND LATER DEVELOPED HIS OWN SUPER UNIT AT ODSTOCK ON THE SALISBURY PLAIN WITHIN THE SHADOW OF STONE HENGE BARRON SKILLED IN JOINERY WHETHER IN WOOD OR FLAPS AND GRAFTS WAS ONE OF MY EARLY TEACHERS WHILE HE WAS AT ROOKSDOWN JOHN BARRON HOUSE BASINGSTOKE RECALL VIVIDLY HIS GENEROSITY RESONANT VOICE FLUENT FRENCH ORIGINAL DESIGN OF SUBCUTANEOUS PEDICLED FLAPS AND THIS 1948 SECONDARY BILATERAL CLEFT CASE OF HIS IN WHICH HE CLEVERLY DESIGNED ESSER CHEEK ROTATION FLAPS 633

6 IN 1946 AUGUST LINDEMANN ADVOCATED CHEEK FLAPS FOR CON STRUCTION OF THE UPPER LIP AND COLUMELLA IN SEVERE SECONDARY CASE HIS DESIGN WAS IN PRINCIPLE SIMILAR TO HIS PRIMARY DESIGN FOR SEVERE BILATERAL CLEFT IN WHICH HE SHIFTED THE PROLABIUM INTO THE COLUMELLA 4N THW SI IN 1967 PERE GABARRO OF BARCELONA STATED HIS PREFERENCE FOR THIS BILATERAL CHEEK ROTATION WHILE SHIFTING THE PROLABIUM INTO THE COLUMELLA FOR HIS SECONDARY CORRECTION OF BILATERAL CLEFTS HE IS AN ARTIST AND THESE ARE HIS OWN SKETCHES 5K 634

7 PERSONAL CASES CHEEK FLAPS AND ABBE FLAP 1LERE IS CASE IN WHICH THE PROLABIUM HAD BEEN AD VANCED INTO THE COLUMELLA AND THE LATERAL LIP ELEMENTS DRAWN TOGETHER IN THE MIDLINE WITH RETENTION SUTURES THE RESULT WAS SHORT TIGHT SCARRED LIP WITH AN INVISIBLE FREE BORDER VERMILION THE CORRECTION REQUIRED SIMULTANEOUS THINNING AND FURTHER ADVANCEMENT OF THE PROLABIUM INTO THE COLUMELLA RADICAL MIDLINE LIP SCAR EXCISION BILATERAL ADVANCEMENT OF CHEEK FLAPS BILATERAL ELLIPTICAL CUPIDS BOW SKIN EXCISIONS ABOVE THE MUCOCUTANEOUS JUNCTION AND MIDLINE LIP CLOSURE OF MUCOSA MUSCLE AND SKIN WITH MEDIAL ADVANCEMENT OF THE ALAR BASES ONE AND HALF YEARS LATER THE LIP RESULT WAS IIOT AS GOODAS THE EARLY POSTOPERATIVE CONDITION PROMISED 635

8 IMPROVEMENT IN THE NOSE WAS PERMANENT BUT EVIDENTLY THE ORIGINAL LIP DISCREPANCY HAD BEEN TOO GREAT FOR LOCAL TISSUE SHIFT ING BY ADVANCEMENT FLAPS THE PRESENCE OF MIDLINE SCAR THE LACK PHILTRUM AND CUPIDS BOW AND THE RELATIVE TIGHTNESS OF THE UPPER LIP IN RELATION TO THE LOWER HAVE MORE OR LESS FORCED SECONDSTAGE SMALL SHIELDSHAPED ABBE FLAP THE PEDICLE WAS DIVIDED AFTER 14 DAYS AND THE PATIENT HAPPY WITH HIS FLAP AND GROWING MUSTACHE RETURNED TO HIS ISLAND IN THE BAHAMAS AND WAS NEVER SEEN AGAIN 44 PROLABIUM INTO COLUMELA AND ABBE FLAP THIS PATIENT BILATERAL CLEFT OF THE LIP AND PALATE WAS CLOSED WITH THE BLAIR BROWN INFERIOR TRIANGULAR FLAPS IN INFANCY IN TENNESSEE AT 26 YEATS HE HAD SHORT TIGHT UPPER LIP WITH CENTRAL BULGING PROLABIUM SHORT COLUMELLA FLAT NASAL TIP ASYMMETRICAL NOSTRILS AND FLARING ALAE MORE MARKED ON THE RIGHT THE NASAL DEFORMITY WAS ACCENTUATED BY THE HIGH NASAL BRIDGE AND THE DEVIATED SEPTUM

9 HERE IS CASE IN WHICH THERE IS DEFINITE ADVANTAGE TO COR RECTING THE NOSE AND LIP AT THE SAME TIME THC PRULABIUM WAS EKVARCD OUT THC LIP WITH THE AID OF MEMBRANOUS SEPTAL INCISION DIVERGING LATERALLY AS ANTERIOR YES TIBULAR INCISIONS REDUCTION RHINOPLASRY WAS POSSIBLE THE ALAR CARTILAGES WERE REDUCED THE HUMP WAS LOWERED THE SEPTUM WAS SHORTENED AND SUBMUCOUS RESECTION REMOVED THE AIRWAY OB STRUCTION IN THE COURSE OF LOWERING THE BRIDGE CARTILAGE FLAP WAS TURNED TOWARD THE TIP TO OFFER EXTRA SUPPORT THE PROLABIUM WAS THINNED AND ROLLED ON ITSELF AS HEMICOLUMN AND AFTER BEING ADVANCED ALONG THE SEPTUM TO ELEVATE THE TIP WAS SUTURED RR SMR THE INFERIOR END OF THE PROLABIUM FLAP WAS SPLIT AND SPLAYED TO FORM COLUMELLA BASE TO JOIN THE ALAR BASES ACROSS THE NOSTRIL SILL THE UPPER LIP WAS NOW COMPLETELY DIVIDED IN THE MIDLINE AND CM SHIELDSHAPED ABBE FLAP WAS TRANSPOSED FROM THE LOWER LIP TO CREATE PHILTRUM THE PEDICLE WAS DIVIDED AFTER 10 DAYS AND 18 MONTHS LATER SANDPAPER ABRASION OF SCARS GAVE THE FINISHING TOUCH 29 YEARS FORKED FLAP AND ABBE FLAP ASYMMETRICAL BILATERAL COMPLETE AND INCOMPLETE CLEFTS OF THE LIP HAD BEEN CLOSED IN INFANCY IN CALIFORNIA BY THE AGE OF 14 YEARS THE PATIENT REVEALED SHORT COLUMELLA SNUBBED NASAL TIP ASYM 637

10 METRICAL NOSTRILS SHORT UPPER LIP WITH PROLABIUM FORMING THE CENTRAL SEGMENT BUT WITH EVERRED THICKENED VERMILION FREE BORDER RIDING HIGH WITH SINGLE MUCOCUTANEOUS ARC AND NO SEMBLANCE OF CUPIDS BOWTHERE WAS EVIDENCE NF SPARSE HAIR IN THE PROLABIUM WHICH AT FIRST DISCOURAGED ITS USE FOR COLUMELLA LENGTHENING 14 YEARS FORKED FLAP INCORPORATING THE BILATERAL SCARS ALLOWED COLU MELLA LENGTHENING AND RELEASE OF THE NASAL TIP SCARS AND INCISIONS EVIDENTLY DISHEARTENED WHAT HAIR FOLLICLES WERE INCLUDED IN THE FORK AS THEY NEVER REARED THEIR SHOOTS THEREAFTER ADVANCEMENT OF THE LIP ELEMENTS TO CLOSE THE FORKED FLAP DONOR AREA DID GIVE SOME VERTICAL LENGTH TO THE LIP YET THE INHERENT SHORTNESS OF TISSUE WAS STILL REFLECTED IN THE REENTRANT NASOLABIAL ANGLE SUBSEQUENT THIN NING OF THE VERMILION FREE BORDER AND GILLIES CUPIDS BOW OERATION WERE ONLY MODERATELY SUCCESSFUL 638

11 SLIGHT RETRACTION OF THE COLUMELLA AND LONG SIDEWALLS PROMPTED BILATERAL ALAR CHONDROMUCOSAL FLAPS BASED SUPERIORLY TO BE TRANS POSED TO EACH OTHER INTO MEMBRANOUS SEPRAL RELEASING INCISION THE UPPER LIP WAS SPLIT IN THE MIDLINE AND RELEASED FROM ABOVE BY HIGH TRANSVERSE INCISIONS LATERALLY TO GIVE WIDTH AND LENGTH TO THE LIP WSHAPED ABBE FLAP WAS TURNED 180 DEGREES INTO THE DEFECT IN THE UPPER LIP AND THE PEDICLE DIVIDED AFTER 14 DAYS CMF THE EXCESS OF COLUMELLA ABOVE AND ITS INFERIOR DEFICIENCY WAS NOT TREATED BUT SOLUTION TO THIS NASTY LITTLE PROBLEM WAS LATER DEVELOPED IS DESCRIBED AT THE END OF CHAPTER 47 AND IS AVAILABLE FOR THIS FINE GENTLEMAN SHOULD HE EVER RETURN FR PROLABIUM INTO COLUMELLA AND ABBE FLM DURING AND AFTER THE ORIGINAL OPERATION ON THIS BILATERAL CLEFT LIP AND PALATE WHICH INCORPORATED THE PROLABIUM IN THE LIP THERE HAD BEEN 27YEAR TUGOFWAR BETWEEN THE NASAL TIP AND THE UPPER 27 YEARS 639

12 LIP AS OFTEN HAPPENS BOTH WERE LOSERS AS THE LIP WAS PULLED UP AND THE TIP PULLED DOWN AT 27 YEATS THE PROLABIUM WAS ADVANCED INTO THE COLUMELLA WITH EXPOSURE FOR ALAR CARTILAGE AND HUMP REDUCTION SEPTAL SHORTENING BILATERAL OSREOTOMIES SUBMUCOUS RESECTION SEPTAL CARTILAGE STRUT TO THE NASAL TIP AND BILATERAL ADVANCEMENT OF THE LATERAL LIP ELEMENTS TO EACH OTHER IN THE MIDLINE RR SMR YEAIS IN OF THE SPITE SLIGHT TIGHTENING OF THE UPPER LIP THE RELEASE OF THE NOSE PRESENTED FACE WITH CONTENTED COMPOSURE WHICH LASTED THREE YEARS FINALLY THE PATIENT WAS PREVAILED UPON TO ACCEPT SMALL MIDLINE SHIELDSHAPED ABBE FLAP IT BECAME FUNCTIONAL AND WAS EMBELLISHED WITH MUSTACHE DEFINITELY IN VOGUE TODAY 39 YEARS 640

13 THIS BILATERAL CLEFT LIP AND PALATE HAD HAD SEVERAL OPERATIONS IN CHICAGO AND ELSEWHERE BY AGE 16 YEARS WHAT REMAINED OF THE PATIENTS PROLABIUM AFTER ZPLASTY INTERDIGITATIONS OF LATERAL FLAPS INTO ITS SIDES WAS OF MINIMAL VALUE TO THE LIP ANY MORE THE LIP WAS SO SCARRED SHORT AND TIGHT THAT EVEN IN IT REPOSE EXPOSED THE ENTIRE INCISORS AND COMPARED UNFAVORABLY WITH THE PROTUBERANT LOWER LIP THE NOSE WITH ITS FLARED ALAE ASYMMETRICAL NOSTRILS AND SHORT COLUMELLA POSED AN UNUSUAL CHALLENGE AS ITS ROMAN BRIDGE ROUNDED ABRUPTLY AT THE FLATTENED TIP WITH FORWARD PROJECTION LITTLE BETTER THAN THAT OF THE LOWER LIP CLASSIC NOSE PRESSED AGAINST WINDOWPANE 16 YEARS THE PROLABIUM WAS CUT OUT OF THE LIP ELEVATED AND ATTACHED TO TILE BASE OF THE COLUMELLA EXPOSURE THROUGH MEMBRANOUS SEPTAL INCISION EXTENDED BILATERALLY AS ANTERIOR VESTIBULAR INCISIONS MADE POSSIBLE REDUCTION OF THE ALAR CART ILAGES WITH SUTURING OF THEIR MEDIAL CRURA AT THE TIP LOWERING OF THE BRIDGE WITH SAW AND CHISEL AND NARROWING OF THE NASAL BONES BY BILATERAL OSREOROMY THE PROLABIUM WAS THINNED ROLLED ON ITSELF AND ADVANCED AS COLUMELLA THE ALAR BASES AND SUPERIOR PORTIONS OF THE LATERAL LIP ELEMENTS WERE ADVANCED MEDIALLY AND SUTURED WITH NYLON TO THE SEPTUM AT THE NASAL SPINE AN ABBE FLAP 15 CM LONG SKIN LENGTH WAS TRANSPOSED INTO THE UPPER LIP DEFECT AND THE PEDICLE RR DIVIDED AFTER 10 DAYS ACS 641

14 1VOW 16 YEARS EIGHT MONTHS LATER ROUNDED TIP AND HANGING COLUMELLA WERE TREATED WITH ALAR CARTILAGE REDUCTION SEPTAL SHORTENING BRIDGE LOWERING AND ALAR BASE RESECTIONS 17 YEARS ONE YEAR LATER FINAL REFINEMENTS INCLUDED MEMBRANOUS SEPTAL 14 SMR EXCISIONS OF COLUMELLA OVERHANG SUBMUCOUS RESECTION WITH SEPRAL SCS2 CARTILAGE STRUTS INSERTED INTO THE COLUMELLA TO SUPPORT THE RIP SCS4 ANOTHER STRUT ALONG THE ALAR RIM AND DENUDED TIPS OF ALAR BASE AB2 FLAPS SUTURED TO EACH OTHER AT THE SEPTUM WITH MERSILENE 642

15 18 YEARS FORKED FLAP AND RHINOPLASTY AN ASYMMETRICAL BILATERAL CLEFT OF THE LIP HAD BEEN CLOSED IN INFANCY IN SOUTH AMERICA BY APPROXIMATION OF THE LATERAL LIP ELEMENTS TO THE SIDES OF THE PROLABIUM AT FOUR AND HALF YEARS OF AGE THIS BOY HAD SHORT CENTRAL SEGMENT OF THE LIP WITH THE ORIGINAL PROLABIUM VERMILION STILL PRESENT AND MODERATELY SHORT COLUMELLA WITH SLIGHT DRAG ON THE NASAL TIP YEARS 643

16 ZZ PHILTRUM WAS SHIFTED INTO THE COLUMELLA WITH RELEASE OF THE NASAL FORKED FLAP TAKING THE BILATERAL LIP SCARS AND RESHAPING THE TIP SIX MONTHS LATER THE PROLABIUM VERMILION WAS TURNED DOWN AND LATERAL VCRMILIUN FLAPS WERE USED TO OVERLAP IT CREATING FF MORE NATURAL VERMILLION FREE BORDER AND TUBERCIE TT YEARS YEARS 67 YELRS G4 644

17 AT 17 YEARS CORRECTIVE RHINOPLASRY INCLUDED REDUCTION OF ALAR CARTILAGES LOWERING OF THE BRIDGE BILATERAL OSREOTOMY ALAR WEDGE RR SMR RESECRIONS COLUMELLA THINNING WITH AN ELLIPTICAL EXCISION SUB AB1 SCS2 MUCOUS RESECTION AND TWO SEPRAL CARTILAGE STRUTS IN THE COLUMELLA TO REFINE THE TIP SILASTIC SPONGE IMPLANT TO THE CHIN WAS INSERTED INTO POCKET THROUGH STAB INCISION IN THE LOWER LABIAL SULCUS 18 YEARS AM PROBLEMS AT THIS POINT WERE SHORT UNDIMPLED PROLABIUM WI TRANSVERSE CREASE AT ITS JOIN WITH THE COLUMELLA BASE AND OF COURSE SEVERELY PROTUBERANT LOWER LIP THE PATIENT REFUSED AN ABBE FLAP OFFERED TO IMPROVE THE UPPER LIP WHILE REDUCING THE LOWER LIP BECAUSE HE DID NOT WANT TO RISK THE EXTRA LOWER LIP SCAR HEREFORE REVISION OF THE CUPIDS BOW THROUGH MUCOCURA NEOUS LINE INCISION ALLOWED ELEVATION OF THE PROLABIUM SKIN DISSECTION OF SUBCUTANEOUS FLAP OUT OF THE CENTER OF THE PROLA BIUM AND TUNNELING OF THIS FLAP UNDER THE UPPER LIP CREASE INTO THE COLUMELLA THE PROLABIUM SKIN WAS TACKED WITH BURIED 40 MERSILENE ETHICON R691G INTO THE EXCAVATION AND FURTHER MOLDED AS PHILTRUM DIMPLE WITH THROUGHANDTHROUGH SUTURE TIED OVER COTTON BOLUS THE LOWER LIP WAS REDUCED BY LONG TRANSVERSE EXCISION OF AN ELLIPSE OF POSTERIOR MUCOSA AND ORBICU LARIS ORIS MARGINALIS 645

18 1RL YEARS IT WAS PREDICTED THAT COMPOSITE WEDGE RESECTION OF THE LOWER LIP INCLUDING SKIN WILL BE NECESSARY TO TIGHTEN THE LIP TO IDEAL PROPORTIONS PROABIUM INTO COUMELLA AND ABBE FLAP BILATERAL CLEFT OF THE LIP AND PALATE HAD BEEN CLOSED IN MICHIGAN IN INFANCY WITH MODERATE AMOUNT OF SCARRING AND SHORTNESS OF THE COLUMELLA AND LIP AT II YEARS THE BEST PORTION OF THE PROLABIUM WAS ADVANCED INTO THE COLUMELLA TO RELEASE THE NASAL TIP AND ITS INFERIOR END WAS SPLIT TO RECEIVE MIDLINE SHIELDSHAPED ABBE FLAP FROM THE LOWER LIP THE PEDICLE WAS DIVIDED AFTER 10 DAYS MINOR SCAR REVISIONS FOLLOWED

19 II II 12 YEARS 20 YEARS FORKED FLAP THIS EIGHTYEAROLD BOY HAD HIS BILATERAL CLEFT OF THE LIP AND PALATE CLOSED BY APPROXIMATION OF LATERAL ELEMENTS TO PROLABIUM WITH SPREAD OF THE PROLABIUM SNUBBING OF THE NASAL TIP AND FLARING OF THE ALAE II FORKED FLAP INCORPORATING THE BILATERAL SCARS AND PORTIONS OF THE PROLABIUM WAS ADVANCED ALONG THE MEMBRANOUS SEPTUM TUBED ON ITSELF IN THE UPPER PORTION AND ALLOWED TO SPLAY AT THE BOTTOM TO JOIN THE MEDIAL ADVANCED ALAR BASE 647

20 16 YEARS RHINOPLASTY AND ABBE FLAP THIS BILATERAL CLEFT OF THE LIP AND PALATE WAS TREATED BY MANY OPERATIONS IN NEW YORK BY AGE 16 YEARS THE PATIENT REVEALED HIGHBRIDGED HOOKED NOSE WITH LARGE NOSTRILS AND SCARRED RE TRACTED COLUMELLA OVERPOWERING SHORT TIGHT WHISKERSCARRED UPPER LIP WHICH IN REPOSE EXPOSED BOTH CENTRAL INCISORS IN THEIR ENTIRETY 648

21

22 CORRECTIVE RHINOPLASTY INCLUDED REDUCTION OF ALAR CARRILAGES REMOVAL OF HUMP SLIGHT SEPTAL SHORTENING BILATERAL OSTEOTOMIES AND CARTILAGE STRUT FROM THE BRIDGE GRAFTED INTO THE COLUMELLA FOR NASAL TIP PERSISTED DEFINITION THE WHISKER STITCH MARK SCARS OF THE LIP ONE YEAR LATER THE SCARRED SKIN OF THE CENTRAL LIP WAS EXCISED AND THE MUCOSA AND VERMILION WERE USED TO COVER THE RAW AREA OF RR CS THE UPPER LABIAL SULCUS THE ALAR BASES WERE CUT FREE FROM THE LIP ELEMENTS SO THE ALAR BASES COULD BE ADVANCED TO THE COLUMELLA AND THE LATERAL LIP ELEMENTS SUTURED TO EACH OTHER IN THEIR UPPER PORTION THIS PROCEDURE REDUCED THE AMOUNT OF SKIN SCARRING LENGTHENED THE LIP BUT PRODUCED CENTRAL SHIELDSHAPED 125 CM ABBE FLAP WAS TRANSPOSED GAP MIDLINE INTO THE DEFECT AND THE PEDICLE DIVIDED IN 10 DAYS OTHER MINOR REVISIONS IN CLUDED DENUDING THE TIPS OF THE ALAR BASE FLAPS AND SUTURING THEM TOGETHER AT THE NASAL SPINE FOR FINAL REDUCTION OF ALAR FLARE VY AB2 ADVANCEMENT OF VERMILION OF ABBE FLAP TO CREATE CENTRAL TUBER CLE AND METHYLENE BLUE PAINTING OF REMAINING SKIN SCARS FOLLOWED BY SANDPAPER ABRASION 19 YEARS 649

23 RHINOPASTY PROABIUM INTO COUMELA AND ABBE FLAP THIS BILATERAL CLEFT OF THE LIP AND PALATE HAD THE LIP CLOSED IN INFANCY WITH INCORPORATION OF THE PROLABIUM INTO THE LIP MOST OF THE PREMAXILLA HAD BEEN LOST AND THE WIDE CLEFT IN THE PALATE HAD NEVER BEEN CLOSED SO THAT THE PATIENT HAD TO USE DENTAL PLATE WITH PALATAL PROSTHESIS AND PHARYNGEAL BULB AT AGE 23 YEARS HE PRESENTED SHORT UPPER LIP WITH WHISTLING DEFORMITY HAIRLESS PROLABIUM SHORT COLUMELLA DEPRESSED NASAL TIP AND FLARING ALAR BASES THERE WAS RELATIVE PROGNARHISM OF THE MANDIBLE WHEN COMPARED TO THE LACK OF PREMAXILLA AND DEFICIENCY OF THE CLEFT MAXILLARY SEGMENTS EVEN MUSTACHE AND BEARD DID NOT HELP MUCH 650

24 THE PROLABIUM WAS CUT OUT OF THE LIP AND WITH THE AID OF MEMBRANOUS SEPTAL AND BILATERAL ANTERIOR VESTIBULAR INCISIONS WAS ELEVATED OUT OF THE WAY TO FACILITATE REDUCTION RHINOPLASTY THE ALAR CARTILAGES WERE REDUCED THE HUMP WAS REMOVED AND THE SEPTUM WAS SHORTENED THE SMALL BONY KNOB OF THE PREMAXILLA WAS SMOOTHED DOWNAND THE MUCOSA USED TO SURFACE THE AREA THE PROLABIUM WAS THINNED SHAPED AND ROLLED ON ITSELF WITH SUBCU RANEOUS 40 CHROMIC CATGUT SUTURES TO FORM NATURAL COLUMELLA RR AB3 THEN ADVANCED ALONG THE MEMBRANOUS SEPTUM AND SUTURED ITS INFERIOR BASE WAS SPLIT TO RECEIVE THE TAIL OF THE ABBE FLAP THE ALAR BASES WERE FREED FROM THE LATERAL LIP SEGMENTS BY CIRCUMALAR INCISIONS THEN EACH WAS DIVIDED INTO TWO FLAPS SUBCUTANEOUS FLAP AND SKIN FLAP THE SUBCUTANEOUS FLAPS WERE SUTURED TO EACH OTHER AT THE BASE OF THE SEPTUM AND THE SKIN FLAPS WERE ADVANCED ACROSS THE NASAL FLOORS TO THE COLUMELLA TO FORM THE NOSTRIL SILLS THE LATERAL LIP SEGMENTS WERE ADVANCED MEDIALLY AND HUNG TO THE SEPTUM CREATING PHILTRUMSIZED DEFECT THEN CM SHIELDSHAPED ABBE FLAP MEASURING 13 CM SKIN LENGTH WAS TRANSPOSED INTO THE UPPER LIP WITH ITS TAIL TUCKED INTO THE PROLABIUM SPLIT TO CAMOUFLAGE THE NEW UNION OF LIP AND NOSE THE PEDICLE WAS DIVIDED AFTER 11 DAYS WHENTHE PATIENT WAS LAST SEEN THREE WEEKS AFTER THE OPERATION THE POSSIBILITIES OF MAXIL LARY ADVANCEMENT WERE DISCUSSED 24 YEARS 651

25 PROLABIUM INTO COUMELA AND ABBE FLAP THIS BILATERAL CLEFT OF THE LIP AND PALATE WAS CLOSED IN INFANCY WITH THE BLAIRBROWN TYPE OF LATERAL TRIANGULAR FLAPS INTRODUCED ABOVE THE INFERIOR EDGE OF THE PROLABIUM BUT WITH SMALL AMOUNT OF ORIGINAL PROLABIUM VERMILION RETAINED IN THE CENTER AT 11 YEARS OF AGE THE UPPER LIP WAS SHORT TIGHT WITH TRAPDOOR PROLABIUM TINY WHISTLING DEFORMITY AND LARGE LEFT BUCCAL SULCUS ORONASAL FISTULA THE SHORT COLUMELLA FLATTENED NASAL TIP AND FLARING ALAE GAVE THE USUAL ANGRY SNORTING EFFECT 11 YEARS AS VISITING PROFESSOR AT THE MASSACHUSETTS GENERAL HOSPITAL WAS INVITED TO CARRY OUT MY USUAL ONESTAGE NASAL AND LABIAL CORRECTION THE PROLABIUM WAS FREED FROM THE LIP THINNED AND CURLED ON ITSELF AND ADVANCED ALONG THE SEPTUM AS COLUMELLA WITH RELEASE OF THE NASAL TIP THE ALAR BASES WERE CUT AS FLAPS DENUDED OF EPITHELIUM AT THEIR TIPS ADVANCED AND SUTURED TO THE SEPTUM AT THE NASAL SPINE THE MUCOSA OF THE PROLABIUM WAS USED AS FLAP TO CLOSE THE ORONASAL FISTULA THEN MIDLINE SHIELDSHAPED ABBE FLAP WAS TRANSPOSED INTO THE CENTER OF THE UPPER LIP TO CREATE PHILTRUM THE PEDICLE WAS 652

26 DIVIDED AFTER 12 DAYS AND THE PHOTOGRAPHS WERE FORWARDED BY JOSH TOFIELD ABOUT TWO MONTHS AFTER THE SURGERY 653